Predicting complicated appendicitis based on clinical findings: the role of Alvarado and appendicitis inflammatory response scores

PURPOSE: The pre-interventional differentiation between complicated and uncomplicated appendicitis is decisive for treatment. In the context of conservative therapy, the definitive diagnosis of uncomplicated appendicitis is mandatory. This study investigates the ability of clinical scoring systems and imaging to differentiate between the two entities. METHODS: This is a retrospective analysis of two cohorts from two tertiary referral centers in Switzerland and Germany. All consecutive patients underwent appendectomy between January 2008 and April 2013 (in the first cohort) or between January 2017 and June 2019 (the second cohort). Exclusion criteria did not apply as all patients found by the database search and received an appendectomy were included. Diagnostic testing and calculation of a receiver operating curve were performed to identify a cutoff for clinical scores that resulted in a minimum sensitivity of 90% to detect complicated appendicitis. The cutoff was combined with additional diagnostic imaging criteria to see if diagnostic properties could be improved. RESULTS: Nine hundred fifty-six patients were included in the analysis. Two hundred twenty patients (23%) had complicated appendicitis, and 736 patients (77%) had uncomplicated appendicitis or no inflammation. The complicated appendicitis cohort had a mean Alvarado score of 7.03 and a mean AIR of 5.21. This compared to a mean Alvarado of 6.53 and a mean AIR of 4.07 for the uncomplicated appendicitis cohort. The highest Alvarado score with a sensitivity of > 90% to detect complicated appendicitis was >== 5 (sensitivity = 95%, specificity 8.99%). The highest AIR score with a sensitivity of > 90% to detect complicated appendicitis was >== 3 (sensitivity 91.82%, specificity 18.53). The analysis showed that additional CT information did not improve the sensitivity of the proposed cut-offs. CONCLUSION: AIR and Alvarado scores showed limited capability to distinguish between complicated and uncomplicated appendicitis even with additional imaging in this retrospective cohort. As conservative management of appendicitis needs to exclude patients with complicated disease reliably, appendectomy seems until now to remain the safest option to prevent undertreatment of this mostly benign disease

Cosmological solutions of massive gravity on de Sitter

In the framework of the recently proposed models of massive gravity, defined with respect to a de Sitter reference metric, we obtain new homogeneous and isotropic solutions for arbitrary cosmological matter and arbitrary spatial curvature. These solutions can be classified into three branches. In the first two, the massive gravity terms behave like a cosmological constant. In the third branch, the massive gravity effects can be described by a time evolving effective fluid with rather remarkable features, including the property to behave as a cosmological constant at late time.Comment: 6 pages, 1 figure; discussion extended, a few references added, improved analysis in Section

Brane Induced Gravity, its Ghost and the Cosmological Constant Problem

"Brane Induced Gravity" is regarded as a promising framework for addressing the cosmological constant problem, but it also suffers from a ghost instability for parameter values that make it phenomenologically viable. We carry out a detailed analysis of codimension > 2 models employing gauge invariant variables in a flat background approximation. It is argued that using instead a curved background sourced by the brane would not resolve the ghost issue, unless a very specific condition is satisfied (if satisfiable at all). As for other properties of the model, from an explicit analysis of the 4-dimensional graviton propagator we extract a mass, a decay width and a momentum dependent modification of the gravitational coupling for the spin 2 mode. In the flat space approximation, the mass of the problematic spin 0 ghost is instrumental in filtering out a brane cosmological constant. The mass replaces a background curvature that would have had the same function. The optical theorem is used to demonstrate the suppression of graviton leakage into the uncompactified bulk. Then, we derive the 4-dimensional effective action for gravity and show that general covariance is spontaneously broken by the bulk-brane setup. This provides a natural realization of the gravitational Higgs mechanism. We also show that the addition of extrinsic curvature dependent terms has no bearing on linearized brane gravity.Comment: v2: LaTeX, JHEP style, 41 pages, 3 eps figures. Partly rewritten to improve presentation, results unchanged, published versio

Keeping Steady as She Goes: A Negotiated Order Perspective on Technological Evolution

A central idea in the theory of technology cycles is that social and political mechanisms are most important during the selection of a dominant design, and that eras of incremental change are socially uninteresting periods in which innovation is driven by technological momentum and elaboration of the dominant design. In this essay, we overturn the ontological assumption that social order is inherently stable, drawing on Anselm Strauss's concept of negotiated order to analyze the persistence of a dominant design as a social accomplishment: an outcome of ongoing processes that reinforce or challenge a socially negotiated order. Thus, we shift focus from battles over standards to periods of normal innovation. We extend the technology cycles model to explain social dynamics in periods of incremental change, and to make predictions specifying how contextual conditions in standards-setting organizations affect social interaction, leading to reinforcement or challenge to a socio-technical order

Cosmological perturbations in Massive Gravity and the Higuchi bound

In de Sitter spacetime there exists an absolute minimum for the mass of a spin-2 field set by the Higuchi bound m^2 \geq 2H^2. We generalize this bound to arbitrary spatially flat FRW geometries in the context of the recently proposed ghost-free models of Massive Gravity with an FRW reference metric, by performing a Hamiltonian analysis for cosmological perturbations. We find that the bound generically indicates that spatially flat FRW solutions in FRW massive gravity, which exhibit a Vainshtein mechanism in the background as required by consistency with observations, imply that the helicity zero mode is a ghost. In contradistinction to previous works, the tension between the Higuchi bound and the Vainshtein mechanism is equally strong regardless of the equation of state for matter.Comment: 24 pages, typos and conventions correcte

Deep Yedoma permafrost: A synthesis of depositional characteristics and carbon vulnerability

Permafrost is a distinct feature of the terrestrial Arctic and is vulnerable to climate warming. Permafrost degrades in different ways, including deepening of a seasonally unfrozen surface and localized but rapid development of deep thaw features. Pleistocene ice-rich permafrost with syngenetic ice-wedges, termed Yedoma deposits, are widespread in Siberia, Alaska, and Yukon, Canada and may be especially prone to rapid-thaw processes. Freeze-locked organic matter in such deposits can be re-mobilized on short time-scales and contribute to a carbon cycle climate feedback. Here we synthesize the characteristics and vulnerability of Yedoma deposits by synthesizing studies on the Yedoma origin and the associated organic carbon pool. We suggest that Yedoma deposits accumulated under periglacial weathering, transport, and deposition dynamics in non-glaciated regions during the late Pleistocene until the beginning of late glacial warming. The deposits formed due to a combination of aeolian, colluvial, nival, and alluvial deposition and simultaneous ground ice accumulation. We found up to 130 gigatons organic carbon in Yedoma, parts of which are well-preserved and available for fast decomposition after thaw. Based on incubation experiments, up to 10% of the Yedoma carbon is considered especially decomposable and may be released upon thaw. The substantial amount of ground ice in Yedoma makes it highly vulnerable to disturbances such as thermokarst and thermo-erosion processes. Mobilization of permafrost carbon is expected to increase under future climate warming. Our synthesis results underline the need of accounting for Yedoma carbon stocks in next generation Earth-System-Models for a more complete representation of the permafrost-carbon feedback

The osmotic pressure of charged colloidal suspensions: A unified approach to linearized Poisson-Boltzmann theory

We study theoretically the osmotic pressure of a suspension of charged objects (e.g., colloids, polyelectrolytes, clay platelets, etc.) dialyzed against an electrolyte solution using the cell model and linear Poisson-Boltzmann (PB) theory. From the volume derivative of the grand potential functional of linear theory we obtain two novel expressions for the osmotic pressure in terms of the potential- or ion-profiles, neither of which coincides with the expression known from nonlinear PB theory, namely, the density of microions at the cell boundary. We show that the range of validity of linearization depends strongly on the linearization point and proof that expansion about the selfconsistently determined average potential is optimal in several respects. For instance, screening inside the suspension is automatically described by the actual ionic strength, resulting in the correct asymptotics at high colloid concentration. Together with the analytical solution of the linear PB equation for cell models of arbitrary dimension and electrolyte composition explicit and very general formulas for the osmotic pressure ensue. A comparison with nonlinear PB theory is provided. Our analysis also shows that whether or not linear theory predicts a phase separation depends crucially on the precise definition of the pressure, showing that an improper choice could predict an artificial phase separation in systems as important as DNA in physiological salt solution.Comment: 16 pages, 5 figures, REVTeX4 styl

Near-IR Search for Lensed Supernovae Behind Galaxy Clusters - II. First Detection and Future Prospects

Powerful gravitational telescopes in the form of massive galaxy clusters can be used to enhance the light collecting power over a limited field of view by about an order of magnitude in flux. This effect is exploited here to increase the depth of a survey for lensed supernovae at near-IR wavelengths. A pilot SN search program conducted with the ISAAC camera at VLT is presented. Lensed galaxies behind the massive clusters A1689, A1835 and AC114 were observed for a total of 20 hours split into 2, 3 and 4 epochs respectively, separated by approximately one month to a limiting magnitude J<24 (Vega). Image subtractions including another 20 hours worth of archival ISAAC/VLT data were used to search for transients with lightcurve properties consistent with redshifted supernovae, both in the new and reference data. The feasibility of finding lensed supernovae in our survey was investigated using synthetic lightcurves of supernovae and several models of the volumetric Type Ia and core-collapse supernova rates as a function of redshift. We also estimate the number of supernova discoveries expected from the inferred star formation rate in the observed galaxies. The methods consistently predict a Poisson mean value for the expected number of SNe in the survey between N_SN=0.8 and 1.6 for all supernova types, evenly distributed between core collapse and Type Ia SN. One transient object was found behind A1689, 0.5" from a galaxy with photometric redshift z_gal=0.6 +- 0.15. The lightcurve and colors of the transient are consistent with being a reddened Type IIP SN at z_SN=0.59. The lensing model predicts 1.4 magnitudes of magnification at the location of the transient, without which this object would not have been detected in the near-IR ground based search described in this paper (unlensed magnitude J~25). (abridged)Comment: Accepted by AA, matches journal versio

Near-IR search for lensed supernovae behind galaxy clusters: I. Observations and transient detection efficiency

Massive galaxy clusters at intermediate redshift can magnify the flux of distant background sources by several magnitudes and we exploit this effect to search for lensed distant supernovae that may otherwise be too faint to be detected. A supernova search was conducted at near infrared wavelengths using the ISAAC instrument at the VLT. The galaxy clusters Abell 1689, Abell 1835 and AC114 were observed at multiple epochs of 2 hours of exposure time, separated by a month. Image-subtraction techniques were used to search for transient objects with light curve properties consistent with supernovae, both in our new and archival ISAAC/VLT data. The limiting magnitude of the individual epochs was estimated by adding artificial stars to the subtracted images. Most of the epochs reach 90% detection efficiency at SZ(J) ~= 23.8-24.0 mag (Vega). Two transient objects, both in archival images of Abell 1689 and AC114, were detected. The transient in AC114 coincides - within the position uncertainty - with an X-ray source and is likely to be a variable AGN at the cluster redshift. The transient in Abell 1689 was found at SZ=23.24 mag, ~0.5 arcsec away from a galaxy with photometric redshift z=0.6 +/-0.15. The light curves and the colors of the transient are consistent with a reddened Type IIP supernova at redshift z=0.59 +/- 0.05. The lensing model of Abell 1689 predicts ~1.4 mag of magnification at the position of the transient, making it the most magnified supernova ever found and only the second supernova found behind a galaxy cluster. Our pilot survey has demonstrated the feasibility to find distant gravitationally magnified supernovae behind massive galaxy clusters. One likely supernova was found behind Abell 1689, in accordance with the expectations for this survey, as shown in an accompanying analysis paper.Comment: Language-edited version, 9 pages, 6 figures, accepted by A&

The oldest old in England and Wales: a descriptive analysis based on the MRC Cognitive Function and Ageing Study

Objective: to describe the characteristics and survival of the oldest old in England and Wales